SPECIFIC PATIENT CONDITIONS &

AMBULATORY SURGERY
Obesity & Obstructive Sleep Apnea
Obesity is associated with many concomitant disease states, such as
hypertension, diabetes, hyperlipidemia, the combination of the preceding three
disease states (metabolic syndrome), and obstructive sleep apnea (OSA). The
physiological derangements that accompany these conditions include changes in
oxygen demand, carbon dioxide production, alveolar ventilation, and cardiac
output. There is no precise “cutoff” body mass index (BMI) for patients who
may or may not undergo ambulatory surgery. However, Joshi and colleagues
suggest that patients with a BMI less than 40 kg/m2 tolerate ambulatory surgery
adequately, assuming control of comorbidities. Conversely, patients with a BMI
greater than 50 kg/m2 are thought to be at greater risk in the ambulatory surgical
care environment. Patients with obesity and OSA are at increased risk of
postoperative respiratory complications, such as prolonged airway obstruction
and apnea, particularly if they will receive opioids postoperatively. Scores for
predicting the probability of these complications can aid in the preoperative
assessment and referral to a hospital setting (Tables 44–1 and 44–2). However,
the ASA guidelines note that the literature is insufficient to offer guidance as to
which OSA patients can be safely managed on an inpatient versus an outpatient
basis. Although a sleep study is the standard way to diagnose sleep apnea, many
patients with OSA have never been identified as having OSA. Consequently, an
anesthesiologist may be the first physician to detect the presence or risk of sleep
apnea. Preoperative initiation of continuous positive airway pressure (CPAP)
may reduce the incidence of postoperative cardiac complications, according to
ASA guidelines. Avoidance of respiratory depressants to the degree possible
through the use of opioid-sparing multimodal analgesia, neuraxial, and regional
anesthetic techniques is likewise suggested when appropriate. In addition to the

usual discharge criteria, the ASA also recommends that patients at increased
risk from OSA not be discharged to an unmonitored setting until they no longer
are at risk for perioperative respiratory depression. Other ASA
recommendations include:

• Return of room air oxygen saturation to baseline level prior to discharge

• Observation of respiratory function when unstimulated, such as when sleeping

• Consideration of CPAP or noninvasive positive-pressure ventilation (NIPPV)

if frequent airway obstruction or hypoxemia develops postoperatively
• A possible prolonged period of postoperative observation to ensure that
patients with OSA are not at increased risk from postoperative respiratory
depression compared with non-OSA patients undergoing similar procedures

TABLE 44–1 Identification and assessment of obstructive sleep apnea:

example.1,2
The literature is insufficient to offer guidance regarding an appropriate time to
discharge patients with OSA from the surgical facility.

The Society for Ambulatory Anesthesia has issued its own consensus statement
regarding the management of OSA perioperatively (Table 44–3). This
statement recommends the use of the STOP-Bang criteria for preoperative OSA
screening. Additionally, the consensus statement provides a decision tree to
assist in determining which known and presumed OSA patients are candidates
for ambulatory surgery (Figure 44–1). The Society of Anesthesia and Sleep
Medicine has also issued guidelines to assist in the screening for OSA. Their
recommendations are summarized in Table 44–4. Perioperative complications
associated with OSA are increasingly the subject of malpractice litigation.
Difficult airway management and cardiopulmonary arrest associated with death
or brain injury are often the basis of such claims.

FIGURE 44–1 Decision making in preoperative selection of a patient with

obstructive sleep apnea (OSA) scheduled for ambulatory surgery. CPAP,

continuous positive airway pressure. (Reproduced with permission from Joshi G,

Ankichetty S, Gan T, Chung F. Society for Ambulatory Anesthesia consensus statement on
preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory
surgery. Anesth Analg. 2012 Nov;115(5):1060-1068.)

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